Does Parental Involvement in Pediatric Emergency Department Asthma Treatment Affect Home Management?

Scoping review: multiple stakeholders and child asthma management interventions

OBJECTIVE

This study reviewed research to identify interventions aimed at improving asthma management among children by educating parents and other professionals.

DATA SOURCES

PubMed, Medline, and Embase databases were utilized.

STUDY SELECTIONS

Three databases were searched for child asthma management interventions published between 2012-2022 in English. Search terms included children, asthma, intervention(s), community pediatrics, coaches, schools, and stakeholders. Inclusion criteria were being an experimental study focused on children with asthma (birth-18 years), including stakeholder involvement, education, and a community focus. The search yielded 153 articles; nine were reviewed.

RESULTS

In general, stakeholders developed programs that resulted in improvements in asthma symptoms, knowledge of asthma management, perceptions of health care, and decreased emergency health care visits. Successful interventions involved education about asthma management, providing medications, and partnerships with school staff, healthcare teams, and community members. Effective coordination and communication contributed to successful program implementation. Using technology for asthma management education was effective in tracking access to care and facilitated the delivery of medications.

CONCLUSION

The findings indicate that interventions were effective in improving child asthma management. Stakeholder partnerships were critical to the effectiveness of interventions. Marketing the intervention and encouraging communication with parents also fostered success. Being able to assess the home environment and staying in contact with parents were barriers to these interventions. Conducting randomized controlled trials using the interventions found effective in these studies to assess change in symptoms and emergency care visits over time would yield important information about their long-term success and cost for implementation.

Parental administration of inhaled short-acting beta agonists in the pediatric emergency department: a survey of family perspectives

BACKGROUND

The management of children with an asthma exacerbation includes timely systemic corticosteroids and frequent short-acting beta-agonist therapy. In selected patients, inhaled short-acting beta-agonist administration by parents may promote comfort, constitute an educational opportunity for the family, and safely reduce provider workload. Our objective was to evaluate parental satisfaction and perceived safety of this new approach.

METHOD

This was a cross-sectional study, conducted in a tertiary pediatric ED. We investigated patient and parent perspectives on a newly implemented parental short-acting beta-agonist administration program. A convenience sample of families participating in this program was approached for study enrolment. The primary outcome was the proportion of parents and children who were satisfied with the program. We also evaluated the program's safety and impact on asthma education as reported by parents.

RESULTS

From February 2019 to March 2020, 72 of 74 (97%) families approached for enrolment participated in the survey. A vast majority (95%) of parents appreciated the program and 93% would participate again. Among children > 7 years, 86% preferred receiving inhaled short-acting beta-agonist by their parents rather than by a healthcare provider. Nearly all parents (96%) found the program to be "safe" or "very safe". Some participants reported improvements in their inhaler administration technique (25%) and ability to recognize their child's respiratory distress (25%).

CONCLUSION

A novel parental short-acting beta-agonist administration program in the pediatric ED was widely appreciated by participating families. Parents perceived it as being safe, educational, and contributing to their child's comfort.

Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis

BACKGROUND

The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research.

METHODS

We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings.

RESULTS

A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice.

CONCLUSION

Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42014007106.

A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers

BACKGROUND

Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department.

OBJECTIVE

We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations.

METHODS

This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10.

RESULTS

We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority.

CONCLUSIONS

Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.

The Seven Stages of Man: The Role of Developmental Stage on Medication Adherence in Respiratory Diseases

The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested.

Parental Management of Discharge Instructions: A Systematic Review

CONTEXT

Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.

OBJECTIVE

To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.

DATA SOURCES

We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).

STUDY SELECTION

We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.

DATA EXTRACTION

Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.

RESULTS

Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).

LIMITATIONS

The studies were primarily observational in nature.

CONCLUSIONS

Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

The Nature of Family Engagement in Interventions for Children With Chronic Conditions

Recognizing the bi-directional relationship between family functioning and child well-being in the context of childhood chronic conditions, researchers have tested family-focused interventions aimed at promoting both child and family well-being through improving the family's condition management capacity. Based on a sample of 70 interventions for families in which there was a child with a chronic physical condition, this analysis examined the nature of family engagement in the interventions. Data were extracted from the intervention reports using a standardized template; conventional content analysis was used to describe family engagement. Interventions varied in focus, structure, and level of family engagement. Investigators most often sought to improve condition control or management, with parent engagement focused on improving capacity to manage the treatment regimen. Few investigators addressed capacity building in the context of family functioning. Recommendations are made for reporting standards for family-focused interventions and for enhancing the family systems grounding of interventions.

Unmet Needs at the Time of Emergency Department Discharge

OBJECTIVES

Emergency department (ED) discharge requires conveying critical information in a time-limited and distracting setting. Limited health literacy may put patients at risk of incomplete comprehension, but the relationship between discharge communication needs and health literacy has not been well defined. The goal of this study was to characterize the variation in needs and preferences regarding the ED discharge process by health literacy and identify novel ideas for process improvement from parents and patients.

METHODS

This was an in-depth qualitative interview study in two EDs using asthma as a model system for health communication. Adult patients and parents of pediatric patients with an asthma exacerbation and planned discharge were enrolled using purposive sampling to balance across literacy groups at each site. Interviews were audiotaped, transcribed, coded independently by two team members, and analyzed using a modified grounded theory approach. Interviews were conducted until thematic saturation was reached in both literacy groups at each site.

RESULTS

In-depth interviews were completed with 51 participants: 20 adult patients and 31 pediatric parents. The majority of participants identified barriers related to ED providers, such as use of medical terminology, and systems of care, such as absence of protected time for discharge communication. Patients with limited health literacy, but not those with adequate literacy, identified conflicting information between health care sources as a barrier to successful ED discharge.

CONCLUSIONS

Participants across literacy groups and settings identified multiple actionable areas for improvement in the ED discharge process. These included the use of simplified/lay language, increased visual learning and demonstration, and the desire for complete information. Individuals with limited literacy may particularly benefit from increased attention to consistency.

The effectiveness of family-centered transition processes from hospital settings to home: a review of the literature

BACKGROUND AND OBJECTIVES

The quality of care transitions is of growing concern because of a high incidence of postdischarge adverse events, poor communication with patients, and inadequate information transfer between providers. The objective of this study was to conduct a targeted literature review of studies examining the effectiveness of family-centered transition processes from hospital- and emergency department (ED)-to-home for improving patient health outcomes and health care utilization.

METHODS

We conducted an electronic search (2001-2012) of PubMed, CINAHL, Cochrane, PsycInfo, Embase, and Web of Science databases. Included were experimental studies of hospital and ED-to-home transition interventions in pediatric and adult populations meeting the following inclusion criteria: studies evaluating hospital or ED-to-home transition interventions, study interventions involving patients/families, studies measuring outcomes≤30 days after discharge, and US studies. Transition processes, principal outcome measures (patient health outcomes and health care utilization), and assessment time-frames were extracted for each study.

RESULTS

The search yielded 3458 articles, and 16 clinical trials met final inclusion criteria. Four studies evaluated pediatric ED-to-home transitions and indicated family-tailored discharge education was associated with better patient health outcomes. Remaining trials evaluating adult hospital-to-home transitions indicated a transition needs assessment or provision of an individualized transition record was associated with better patient health outcomes and reductions in health care utilization. The effectiveness of postdischarge telephone follow-up and/or home visits on health care utilization showed mixed results.

CONCLUSIONS

Patient-tailored discharge education is associated with improved patient health outcomes in pediatric ED patients. Effective transition processes identified in the adult literature may inform future quality improvement research regarding pediatric hospital-to-home transitions.

A randomized controlled trial of a public health nurse-delivered asthma program to elementary schools

BACKGROUND

Childhood asthma is a serious and common chronic disease that requires the attention of nurses and other school personnel. Schools are often the first setting that children take the lead in managing their asthma. Often, children are ill prepared for this role. Our study evaluated a school-based, multifaceted asthma program that targeted students with asthma and the broader school community.

METHODS

A randomized trial involving 130 schools with grades 1-5 and 1316 children with asthma and their families was conducted. Outcomes of interest for the child, at 1 year, were urgent care use and school absenteeism for asthma, inhaler technique, and quality of life, and for the school, at 14 months, were indicators of a supportive school environment.

RESULTS

Improvements were observed at the child and school level for the intervention group. Fewer children in the intervention group had a school absence (50% vs 60%; p < .01), required urgent care for asthma (41% vs 51%; p < .0001), or reported a day of interrupted activity (51% vs 63%; p < .01), and had improved quality of life (5.8 ± 1.2 vs 5.4 ± 1.4; p < .0001). Schools in the intervention group were more likely to have practices supporting an asthma-friendly environment.

CONCLUSIONS

Implementation of a multifaceted school-based asthma program can lead to asthma-friendly schools that support children with asthma to be successful managers of their asthma and experience improved quality of life and decreased disease associated burden.

Guidelines for aerosol devices in infants, children and adults: which to choose, why and how to achieve effective aerosol therapy

Multiple types of aerosol devices are commonly used for the administration of medical aerosol therapy to patients with pulmonary diseases. All of these devices have been shown to be effective in trials where they are used correctly. However, failure to operate any of these devices properly has been associated with poor clinical response and limited patient adherence to therapy. Therefore, the selection of the best aerosol device for the individual patient is very important for optimizing the results of medical aerosol therapy. This article presents the rationale for selecting the most appropriate aerosol device to administer inhaled drugs in specific patient populations, with emphasis on patient-, drug-, device- and environment-related factors and with a comparison between the available devices. The following recommendations for the selection of the 'best' aerosol device for each patient population are intended to help clinicians gain a clear understanding of the specific issues and challenges so that they can optimize aerosol drug delivery and its therapeutic outcomes in patients.